Azria Health Longview

Inspectors wroteBased on Electronic Health Records (EHR) review and staff interviews the facility failed to provide written notice, including the reason for the change, before the resident's room at the facility was changed for 3 of 3 residents reviewed (Resident #1, #7 and #8). The facility reported a census of 74 residents.

Inspectors wroteBased on observations, staff interviews, Electronics Health Record (EHR) review and policy review the facility failed to ensure residents received required direct supervision during meals and failed to implement specific care-planned interventions during meals with 2 of 2 residents reviewed (Resident #5 and #6). The facility reported a census of 74 residents. Findings Include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #5 did not document a Brief Interview for Mental Status (BIMS) score. The MDS documented Resident #5 had severely impaired daily decision making skills. Review of Resident #5 Electronic Health Record (EHR) titled, Care Plan documented an intervention for eating that Resident #5 required supervision during meals, was at high risk for aspiration, tried to eat quickly and required cues to slow down. [...]

Inspectors wroteBased on observations, staff interviews, Electronic Health Record (EHR) review and policy review the facility failed to provide food at a palatable temperature to 2 of 2 residents (Resident #6 and Resident #9) reviewed. The facility reported a census of 74 residents. Findings Include:The Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview For Mental Status (BIMS) score of 10 indicated moderate cognitive impairment. On 6/9/26 at 9:26 AM a continuous observation revealed Staff D, Certified Nurse Assistant/Certified Medication Assistant (CNA/CMA) escorted Resident #6 into the dining room and retrieved her tray from the kitchen serving window. Staff D was requested by the survey team to return the tray to the kitchen for Staff C, Certified Dietary Manager (CDM) to obtain the temperature of the food items. [...]

Inspectors wroteBased on observations, staff interviews, family interview and policy review the facility failed to store, prepare, and serve food in accordance with professional standards. The facility did not label and date open food items, follow best-by dates, discard expired food items, perform hand hygiene prior to or during food services, complete hand hygiene when obtaining temperatures on food items and did not reheat food in a microwave to an appropriate internal temperature. The facility reported a census of 74 residents.

Inspectors wroteBased on clinical record review, facility investigative file review, staff and pharmacist interviews and facility policy review, the facility failed to ensure 4 of 4 residents (Resident #1, #2, #3 and #5) was free from exploitation. The facility reported a census of 80 residents.

Inspectors wroteBased on the previous Centers for Medicare and Medicaid Services (CMS) form 2567 review, staff interviews and facility policy review the facility failed to ensure they provided a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 80 residents.

Inspectors wroteBased on record review, facility investigative file review, resident and staff interviews and facility policy review the facility failed to ensure 1 of 3 residents (Resident #1) was free from financial exploitation. The facility reported a census of 78 residents.

Inspectors wroteBased on observations, record review, staff interviews and facility policy review the facility failed to ensure fall interventions were in place after 1 of 3 residents (Resident #8) sustained a fall. Resident #8 had a fall on 6/30/2025 that resulted in a hematoma on the right side of his head. Staff updated his care plan to include the placement of non-skid strips in front of his bed. A work order was developed to have the non-skid strip placed but the work order documented the wrong bed number. Resident #8 did not have non-skid strips placed when he sustained a fall on 7/14/2025 and suffered multiple facial fractures and had to be hospitalized . When the survey ended on 7/16/2025, Resident #8 was still in the hospital. The facility reported a census of 82 residents.

Inspectors wrote2. The Minimum Data Set (MDS) dated [DATE] for Resident #39 documented a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. The MDS documented diagnoses of acute and chronic respiratory failure with hypercapnia. Review of Resident #39's EHR titled, Orders documented a physicians order for albuterol sulfate inhalation aerosol solution 2 puffs inhaled orally every 4 hours as needed as needed for 2-4 puffs may keep at bedside. Review of Resident #39's EHR titled, Assessments revealed no medication self administration assessment completed. Review of Resident #39's EHR titled, Care Plan documented no medication self administration plan in place. On 6/9/25 at 1:18 PM an observation in Resident #39's room revealed an albuterol inhaler present on the bed side table next to the resident's bed. [...]

Inspectors wroteBased on observations, call light log review, Electronic Health Record (EHR) review, policy review, resident interview, and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 24 residents reviewed (Resident #25, #29, #39 and #54). The facility reported a census of 86 residents.

Inspectors wroteBased on the previous Centers for Medicare and Medicaid Services (CMS) form 2567 review, staff interviews and facility policy review, the facility failed to ensure they provided a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 86 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to use universal infection control measures and Enhanced Barrier Precautions (EBP) during cares for 4 of 5 residents reviewed for infection control (Residents #38, #57, #61, and #189). The Facility reported a census of 86 residents.

Inspectors wroteBased on observation, Electronic Health Record (EHR) review, resident interviews, staff interviews and policy review, the facility failed to provide dignity and respect to 1 of 3 residents reviewed (Resident #54). The facility reported a census of 86 residents.

Inspectors wroteBased on clinical document review, staff interview, and policy review the facility failed to provide a comprehensive care plan related to high risk medications for residents with an order for diuretics for 1 of 5 residents (Resident# 12) reviewed. The facility reported a census of 86 residents.

Inspectors wroteBased on observation, resident interview, staff interviews, Electronic Health Record (EHR) review and policy review the facility failed to provide timely and adequate treatment and interventions to prevent the worsening of pressure ulcers for 1 of 4 residents reviewed (Resident #61.) The facility failed to request or apply any treatment or dressing to Resident #61's right heel for 8 days until seen by the visiting wound care nurse, to prevent the worsening of the wound. The facility reported a census of 86 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, and policy review the facility failed to assess a resident for safety while smoking for 1 of 2 residents reviewed (Resident #16). The facility reported a census of 86 residents.

Inspectors wroteBased on Electronic Health Records (EHR) review, resident interview, policy review and staff interviews the facility failed to provide dialysis services consistent with professional standards by not completing a post dialysis assessment to 1 of 1 residents reviewed (Resident #39). The facility reported a census of 86 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to serve residents their therapeutic menu as ordered, for 3 of 22 residents (Residents #31, #69 and #6) with mechanically altered diets. The dietary staff ran out of the scheduled vegetable of the day and served corn to residents that required a mechanical soft diet. The facility reported a census of 86 residents.

Inspectors wrote2. According to the Minimum Data Set (MDS) dated [DATE], Resident #136 was independent with self-care and mobile with the use of a wheel chair. His diagnoses included heart failure, renal insufficiency, diabetes mellitus, anxiety disorder and respiratory failure. The following was found in the nursing progress notes for Resident #136: a. On 1/30/25 at 3:35 PM, mental status upon admission oriented x 3 communicated verbally, speech clear, is able to understand and be understood when speaking. Mood was pleasant no unwanted behaviors witnessed. Arrived by private transportation, reported shortness of breath, b. On 1/30/25 at 4:20 PM, he was admitted to the facility from the hospital at 3:00 PM. He had difficulty ambulating and shortness of breath. The resident required 3-4 liters of supplemental oxygen, stated that he wanted physical therapy to evaluate him in the morning. c. [...]

Inspectors wroteBased on observations, review of resident council notes and grievance/complaint logs, resident and staff interviews and facility policy review the facility failed to answer call lights in a timely manner. The facility reported a census of 72 residents.

Inspectors wroteBased on clinical record review, staff interviews, physician interview, and policy review the facility failed to complete physician's orders for 2 of 3 residents (Resident #3 and #4) reviewed. The facility reported a census of 72 residents.

Inspectors wroteBased on clinical record review, staff and resident interviews, and policy review the facility failed to assist 3 of 3 residents (Resident #5, #7 and #8) that were dependent on staff for Activities of Daily Living (ADLs) care when they were incontinent of urine and/or bowel. The facility reported a census of 72 residents.

Inspectors wroteBased on observations, staff interviews, resident interview and clinical record review the facility failed to implement interventions to prevent the worsening of pressure sores for 2 of 3 residents reviewed. While Resident #16 was a resident at the facility, she developed on a pressure sore on her heel. Staff failed to implement orders in a timely manner, failed to use the recommended pressure relieving boots, and failed to apply the treatment properly. Resident #17 had a chronic pressure area on his buttocks and staff failed to use the protective barrier creams as recommended. The facility reported a census of 65 residents.

Inspectors wroteBased on clinical record review, staff interviews, provider interview and policy review the facility failed to provide a professional standard of quality of care by not following physician orders and failing to maintain continence for 2 of 4 residents reviewed (Resident #61, #17). The facility reported a census of 65 residents.

Inspectors wroteBased on observations, resident interviews, staff interviews, resident council notes, and policy review the facility failed to provide food at an appetizing temperature to 4 of 20 residents reviewed (Resident #25, #52, #59, and #61). The facility reported a census of 65 residents.

Inspectors wroteBased on observations, staff interviews, and policy review the facility failed to follow proper sanitation, food safety and food handling practices in accordance with professional standards. The facility reported a census of 65 residents.

Inspectors wroteBased on clincal record review, resident interview, staff interview, and policy review the facility failed to make prompt efforts to resolve grievances the resident may have for 1 of 1 residents reviewed (Resident #52). The facility reported a census of 65 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to complete a Pre-admission Screening and Resident Review (PASRR) for 1 of 1 residents (Resident #25), who was diagnosed with new mental disorder diagnoses since admission to the facility. The facility reported a census of 65 residents.

Inspectors wroteBased on resident interview, staff interview, electronic health records (EHR) review, and policy review the facility failed to maintain medical records on each resident that were complete and accurate by not signing medication administration records when the enteral feeding was given for 1 of 2 residents reviewed (Resident #52). The facility reported a census of 65 residents.

Inspectors wroteBased on observations, staff interviews, clinical record review and facility policy review the facility failed to provide adequate hand hygiene and Enhanced Barrier Precautions (EBP) for 3 of 9 residents reviewed for precaution. Staff failed to change gloves during incontinence cares for Resident #17, and failed to use proper Personal Protective Equipment (PPE) during catheter cares for Residents #25 and #21. The facility reported a census of 65 resident.

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, the facility failed to complete comprehensive, weekly wound assessments of the resident's skin for 2 of 3 residents sampled (Residents #1 and #2). The facility reported a census of 71 residents.

Inspectors wroteBased on observations, clinical record review, and staff interviews, the facility failed to assure residents on pureed diets received appropriate portions for 5 of 5 residents reviewed (Resident #24, #26, #27, #36, and #63). The facility reported a census of 69 residents.

Inspectors wroteBased on observations, staff interview and facility policy review the facility failed to serve food in accordance with professional standards for food service safety. The facility reported a census of 69 residents.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure resident privacy for 1 of 24 residents reviewed (Resident #34). The facility reported a census of 69 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to notify the physician of family reported concerns for 1 of 5 residents reviewed (Resident #70). The facility reported a census of 69 residents.

Inspectors wroteBased on clinical record review, staff interview and facility policy review the facility failed to provide residents or their representatives the appropriate written notices in a timely manner when they no longer qualified for services covered by Medicare for 2 of 3 residents reviewed (Resident #40 and #59). The facility reported a census of 69 residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to refer a resident to the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination who was identified with a newly evident mental disorder for one of three residents reviewed (Resident #36). The facility reported a census of 69 residents.

Inspectors wroteBased on clinical record review, resident and staff interviews and facility policy review, the facility failed to revise the Care Plan with resident specific data after a urinary catheter related hospitalization for 1 of 1 resident reviewed (Resident #40). The facility reported a census of 69 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to follow a physician's order for weekly weights, due to weight loss, for 1 of 17 residents reviewed (Resident #57); and failed to apply compression stockings per physician's orders for 1 of 1 residents reviewed (Resident #80). The facility reported a census of 69 residents.

Inspectors wroteBased on observations, clinical record review, family and staff interviews and facility policy review, the facility failed to provide nail care that resulted in a palm and nose wounds, and failed to provide showers per resident preference for 2 of 24 residents reviewed (Resident #23 and #72). The facility reported a census of 69 residents.

Inspectors wroteBased on clinical record review, family and staff interviews the facility failed to provide adequate assessment and timely intervention for 1 of 5 residents reviewed (Resident #70). The facility reported a census of 69 residents.

Inspectors wroteBased on clinical record review, resident and staff interviews and facility policy review, the facility failed to prevent pressure ulcer development for 1 of 3 resident reviewed for pressure ulcers (Resident #21). The facility reported a census of 69 residents.

Inspectors wroteBased on observations, clinical record review, and staff interviews, the facility failed to ensure safe transfer techniques used for 2 of 3 residents reviewed (Resident # 21, #24). The facility reported a census of 69 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, and facility policy review the facility failed to provide appropriate incontinence care for one of three residents reviewed (Resident #24) . The facility reported a census of 69 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review the facility failed to consistently assess and obtain vitals before and after dialysis for 1 of 1 resident reviewed (Resident #34). The facility reported a census of 69 residents.

Inspectors wroteBased on clinical record review, observation and staff interview the facility failed to ensure staff performed proper hand hygiene during patient care for 1 of 24 residents reviewed (Resident #34). The facility reported a census of 69 residents.